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Clindareach

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Cleocin is used for treating serious infections caused by certain bacteria.

Active Ingredient: Clindamycin

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Polycystic Ovarian Syndrome

Polycystic Ovarian Syndrome Practice Essentials

Women with polycystic ovarian syndrome (PCOS) have abnormalities in the metabolism of androgens and estrogen and in the control of androgen production. PCOS can result from abnormal function of the hypothalamic-pituitary-ovarian (HPO) axis.

Essential update: Endocrine Society publishes guidelines for diagnosis and management of polycystic ovarian syndrome

In October 2013, the Endocrine Society released practice guidelines for the diagnosis and treatment of PCOS. The following are among their conclusions [21].

Use the Rotterdam criteria for diagnosing PCOS (presence of 2 of the following: androgen excess, ovulatory dysfunction, or polycystic ovaries).

In adolescents with PCOS, hyperandrogenism is central to the presentation; hormonal contraceptives and metformin are treatment options in this population.

Postmenopausal women do not have a consistent PCOS phenotype.

Exclude alternate androgen-excess disorders and risk factors for cardiovascular disease, diabetes, endometrial cancer, mood disorders, and obstructive sleep apnea.

For menstrual abnormalities and hirsutism/acne, hormonal contraceptives are first-line treatment.

For infertility, clomiphene is first-line treatment.

For metabolic/glycemic abnormalities and for improving menstrual irregularities, metformin is beneficial.

Metformin is of limited or no benefit for managing hirsutism, acne, or infertility.

Overall, thiazolidinediones have an unfavorable risk-benefit ratio.

More investigation is needed to determine the roles of weight loss and statins in PCOS.

Signs and symptoms

The major features of PCOS include menstrual dysfunction, anovulation, and signs of hyperandrogenism. [1] Other signs and symptoms of PCOS may include the following:

Obesity and metabolic syndrome

The following imaging studies may be used in the evaluation of PCOS:

Ovarian ultrasonography, preferably using transvaginal approach

Pelvic CT scan or MRI to visualize the adrenals and ovaries

An ovarian biopsy may be performed for histologic confirmation of PCOS; however, ultrasonographic diagnosis of PCOS has generally superseded histopathologic diagnosis. An endometrial biopsy may be obtained to evaluate for endometrial disease, such as malignancy.

See Workup for more detail.

Management

Lifestyle modifications are considered first-line treatment for women with PCOS. Such changes include the following [8, 22].

Pharmacologic treatments are reserved for so-called metabolic derangements, such as anovulation, hirsutism, and menstrual irregularities. First-line medical therapy usually consists of an oral contraceptive to induce regular menses.

If symptoms such as hirsutism are not sufficiently alleviated, an androgen-blocking agent may be added. First-line treatment for ovulation induction when fertility is desired is clomiphene citrate. [8, 22, 24]

Medications used in the management of PCOS include the following:

Oral contraceptive agents (eg, ethinyl estradiol, medroxyprogesterone)

Antiandrogens (eg, spironolactone, leuprolide, finasteride)

Hypoglycemic agents (eg, metformin, insulin)

Selective estrogen receptor modulators (eg, clomiphene citrate)

Topical hair-removal agents (eg, eflornithine)

Surgical management of PCOS is aimed mainly at restoring ovulation. Various laparoscopic methods include the following:

See Treatment and Medication for more detail.

Image library Longitudinal transabdominal ultrasonogram of an ovary. This image reveals multiple peripheral follicles. Background

The major features of polycystic ovarian syndrome (PCOS) include menstrual dysfunction, anovulation, and signs of hyperandrogenism. [1] Although the exact etiopathophysiology of this condition is unclear, PCOS can result from abnormal function of the hypothalamic-pituitary-ovarian (HPO) axis. A key characteristic of PCOS is inappropriate gonadotropin secretion, which is more likely a result of, rather than a cause of, ovarian dysfunction. In addition, one of the most consistent biochemical features of PCOS is a raised plasma testosterone level. [2] (See Etiology and Workup.)

Stein and Leventhal were the first to recognize an association between the presence of polycystic ovaries and signs of hirsutism and amenorrhea (eg, oligomenorrhea, obesity). [3] After women diagnosed with Stein-Leventhal syndrome underwent successful wedge resection of the ovaries, their menstrual cycles became regular, and they were able to conceive. [4] As a consequence, a primary ovarian defect was thought to be the main culprit, and the disorder came to be known as polycystic ovarian disease. (See Etiology and Treatment.)

Further biochemical, clinical, and endocrinologic studies revealed an array of underlying abnormalities. As a result, the condition is now referred to as PCOS, although it may occur in women without ovarian cysts and although ovarian morphology is no longer an essential requirement for diagnosis.

Longitudinal transabdominal ultrasonogram of an ovary. This image reveals multiple peripheral follicles. Diagnostic criteria

A 1990 expert conference sponsored by the National Institute of Child Health and Human Disease (NICHD) of the United States National Institutes of Health (NIH) proposed the following criteria for the diagnosis of PCOS:

Oligo-ovulation or anovulation manifested by oligomenorrhea or amenorrhea

Hyperandrogenism (clinical evidence of androgen excess) or hyperandrogenemia (biochemical evidence of androgen excess)

Exclusion of other disorders that can result in menstrual irregularity and hyperandrogenism

In 2003, the European Society for Human Reproduction and Embryology (ESHRE) and the American Society for Reproductive Medicine (ASRM) recommended that at least 2 of the following 3 features are required for PCOS to be diagnosed [5].

Oligo-ovulation or anovulation manifested as oligomenorrhea or amenorrhea

Hyperandrogenism (clinical evidence of androgen excess) or hyperandrogenemia (biochemical evidence of androgen excess)

Polycystic ovaries (as defined on ultrasonography)

Clinical/biochemical evidence of hyperandrogenism

Evidence of ovarian dysfunction (oligo-ovulation and/or polycystic ovaries)

Exclusion of related disorders

The Society of Obstetricians and Gynaecologists of Canada (SOGC) indicated that a diagnosis of polycystic ovarian syndrome (PCOS) is made in the presence of at least 2 of the following 3 criteria, when congenital adrenal hyperplasia, androgen-secreting tumors, or Cushing syndrome have been excluded [8].

Oligo-ovulation or anovulation

Clinical/biochemical evidence of hyperandrogenism

Polycystic ovaries on ultrasonograms (>12 small antral follicles in an ovary)

Etiology

Women with polycystic ovarian syndrome (PCOS) have abnormalities in the metabolism of androgens and estrogen and in the control of androgen production. High serum concentrations of androgenic hormones, such as testosterone, androstenedione, and dehydroepiandrosterone sulfate (DHEA-S), may be encountered in these patients. However, individual variation is considerable, and a particular patient might have normal androgen levels.

In addition, insulin resistance in PCOS has been associated with adiponectin, a hormone secreted by adipocytes that regulates lipid metabolism and glucose levels. Lean and obese women with PCOS have lower adiponectin levels than do women without PCOS. [10]

Hyperinsulinemia is also responsible for dyslipidemia and for elevated levels of plasminogen activator inhibitor-1 (PAI-1) in patients with PCOS. Elevated PAI-1 levels are a risk factor for intravascular thrombosis.

Polycystic ovaries are enlarged bilaterally and have a smooth, thickened capsule that is avascular. On cut sections, subcapsular follicles in various stages of atresia are seen in the peripheral part of the ovary. The most striking ovarian feature of PCOS is hyperplasia of the theca stromal cells surrounding arrested follicles. On microscopic examination, luteinized theca cells are seen.

Some evidence suggests that patients have a functional abnormality of cytochrome P450c17, the 17-hydroxylase, which is the rate-limiting enzyme in androgen biosynthesis. [10]

PCOS is a genetically heterogeneous syndrome in which the genetic contributions remain incompletely described. PCOS is an inherently difficult condition to study genetically because of its heterogeneity, difficulty with retrospective diagnosis in postmenopausal women, associated subfertility, incompletely understood etiology, and gene effect size. [2] Many published genetics studies in PCOS have been underpowered, and the results of published candidate gene studies have been disappointing.

Studies of family members with PCOS indicate that an autosomal dominant mode of inheritance occurs for many families with this disease. The fathers of women with PCOS can be abnormally hairy; female siblings may have hirsutism and oligomenorrhea; and mothers may have oligomenorrhea. [12] Research has suggested that in a large cohort of women with PCOS, a family history of type 2 diabetes in a first-degree family member is associated with an increased risk of metabolic abnormality, impaired glucose tolerance, and type II diabetes. [12] In addition, a Dutch twin-family study showed a PCOS heritability of 0.71 in monozygotic twin sisters, versus 0.38 in dizygotic twins and other sisters. [13]

An important link between PCOS and obesity was corroborated genetically for the first time by data from a case-control study in the United Kingdom that involved 463 patients with PCOS and more than 1300 female controls. [14] The investigators demonstrated that a variant within the FTO gene (rs9939609, which has been shown to predispose to common obesity) was significantly associated with susceptibility to the development of PCOS.

Subsequent studies have found additional associations, such as those of 15 regions in 11 genes previously described to influence insulin resistance, obesity, or type 2 diabetes. [17] Individuals with PCOS were found more likely to be homozygous for a variant upstream of the PON1 gene and homozygous for an allele of interest in IGF2. Interestingly, the PON1 gene variant resulted in decreased gene expression, which could increase oxidative stress. The exact result of the IGF2 variant is unclear, but IGF2 stimulates androgen secretion in the ovaries and adrenal glands. [17]

In study by Goodarzi et al, the leucine allele was found to be associated with protection against PCOS, as compared to the valine allele at position 89 in SRD5A2. [18] The leucine allele is associated with a lower enzyme activity. [18] When the results of this study are combined with those of an observational study by Vassiliadi et al, based on urinary steroid profiles in women with PCOS, further support can be found for an important role for 5-alpha reductase in the pathogenesis of this syndrome. [19]

In a genome-wide association study for PCOS in a Han Chinese population, 3 strong regions of association were identified, at 2p16.3, 2p21, and 9q33.3. [20] The polymorphism most strongly associated with PCOS at the 2p16 locus was near several genes involved in proper formation of the testis, as well as a gene that encodes a receptor for luteinizing hormone (LH) and human chorionic gonadotropin (HCG). This polymorphism was also located 211kb upstream from the FSHR gene, which encodes the follicle-stimulating hormone (FSH) receptor. [20]

The polymorphisms most strongly associated with PCOS at the 2q21 locus encode a number of genes, including the THADA gene, which has previously been associated with type 2 diabetes. In addition, 6 significant polymorphisms were identified as being associated with PCOS at the 9q33.3 locus near the DENND1A gene, which interacts with the ERAP1 gene. Elevation in serum ERAP1 has been previously associated with PCOS and obesity. [20]

Epidemiology

In the United States, polycystic ovarian syndrome (PCOS) is one of the most common endocrine disorders of reproductive-age women, with a prevalence of 4-12%. [25, 26] Up to 10% of women are diagnosed with PCOS during gynecologic visits. [27] In some European studies, the prevalence of PCOS has been reported to be 6.5-8%. [28, 29]

A great deal of ethnic variability in hirsutism is observed. For example, Asian (East and Southeast Asia) women have less hirsutism than white women given the same serum androgen values. In a study that assessed hirsutism in southern Chinese women, investigators found a prevalence of 10.5%. [30] In hirsute women, there was a significant increase in the incidence of acne, menstrual irregularities, polycystic ovaries, and acanthosis nigricans. [30]

PCOS affects premenopausal women, and the age of onset is most often perimenarchal (before bone age reaches 16 y). However, clinical recognition of the syndrome may be delayed by failure of the patient to become concerned by irregular menses, hirsutism, or other symptoms or by the overlap of PCOS findings with normal physiologic maturation during the 2 years after menarche. In lean women with a genetic predisposition to PCOS, the syndrome may be unmasked when they subsequently gain weight. [9]

Prognosis

Evidence suggest that women with polycystic ovarian syndrome (PCOS) may be at increased risk for cardiovascular and cerebrovascular disease. Women with hyperandrogenism have elevated serum lipoprotein levels similar to those of men. [31, 32, 33, 34]

Approximately 40% of patients with PCOS have insulin resistance that is independent of body weight. These women are at increased risk for type 2 diabetes mellitus and consequent cardiovascular complications.

The American Association of Clinical Endocrinologists and the American College of Endocrinology recommend screening for diabetes by age 30 years in all patients with PCOS, including obese and nonobese women. [35] In patients at particularly elevated risk, testing before 30 years of age may be indicated. Patients who initially test negative for diabetes should be periodically reassessed throughout their lifetime.

Patients with PCOS are also at an increased risk for endometrial hyperplasia and carcinoma. [23, 36] The chronic anovulation in PCOS leads to constant endometrial stimulation with estrogen without progesterone, and this increases the risk of endometrial hyperplasia and carcinoma. The Royal College of Obstetricians and Gynaecologists (RCOG) recommends induction of withdrawal bleeding with progestogens a minimum of every 3-4 months. [23]

No known association with breast or ovarian cancer has been found; thus, no additional surveillance is needed. [23]

Patient Education

Discuss with patients the symptoms of polycystic ovarian syndrome (PCOS) as well as their increased risk for cardiovascular and cerebrovascular disease. Educate women with this condition regarding lifestyle modifications such as weight reduction, increased exercise, and dietary modifications. [8, 22, 23] (See Diet and Activity.)

For more information, see Women's Health Center, as well as Ovarian Cysts, Amenorrhea, and Female Sexual Problems.

History

The family history of patients with polycystic ovarian syndrome (PCOS) may include the following:

Adrenal enzyme deficiencies

Obesity and metabolic syndrome

Menstrual abnormalities

Patients with PCOS have abnormal menstruation patterns attributed to chronic anovulation. (The patient usually has a history of menstrual disturbance dating back to menarche.) Some women have oligomenorrhea (ie, menstrual bleeding that occurs at intervals of 35 days to 6 months, with [22]

Infertility

A subset of women with PCOS is infertile. Most women with PCOS ovulate intermittently. Conception may take longer than in other women, or women with PCOS may have fewer children than they had planned. In addition, the rate of miscarriage is also higher in affected women.

Obesity and metabolic syndrome

Nearly half of all women with PCOS are clinically obese. A study comparing the body mass index (BMI) in American and Italian women with PCOS showed that American women had a BMI higher than that of their Italian counterparts. [37] Women with PCOS should be assessed for their cardiovascular risk by evaluating their BMI, fasting lipid and lipoprotein levels, and risk factors for metabolic syndrome. [22, 23]

Many patients with PCOS have characteristics of metabolic syndrome; one study showed a 43% prevalence of metabolic syndrome in women with PCOS. [25] In women, metabolic syndrome is characterized by abdominal obesity (waist circumference >35 in), dyslipidemia (triglyceride level >150 mg/dL, high-density lipoprotein cholesterol [HDL-C] level [25]

Women with PCOS have an increased prevalence of coronary artery calcification and thickened carotid intima media, which may be responsible for subclinical atherosclerosis. Prospective, long-term cardiovascular-outcome studies in PCOS are needed to assess whether the increased cardiovascular risk in PCOS results in the higher cardiovascular-event rates.

Diabetes mellitus

ACOG recommends screening for type 2 diabetes and impaired glucose tolerance in women with PCOS by obtaining a fasting glucose level and then a 2-hour glucose level after a 75-g glucose load. [22] Approximately 10% of women with PCOS have type 2 diabetes mellitus, and 30-40% of women with PCOS have impaired glucose tolerance by 40 years of age. [38, 39]

Sleep apnea

Many women with PCOS have obstructive sleep apnea syndrome (OSAS), which is an independent risk factor for cardiovascular disease. [23] Ask these patients and/or their partners about excessive daytime somnolence; individuals with obstructive sleep apnea experience apnea/hypopnea episodes during sleep. [40, 41] For women with PCOS with suspected OSAS, there should be a low threshold for referral for sleep assessment. Patients may also be screened for OSAS in the clinic using such tools as the Epworth sleepiness score.

Physical Examination Hirsutism and virilizing signs

Patients may have excessive body hair in a male distribution pattern, as well as acne. Some patients have virilizing signs, such as male-pattern balding or alopecia, increased muscle mass, deepening voice, or clitoromegaly; these findings should prompt a search for other causes of hyperandrogenism.

The modified Ferriman-Gallwey (mFG) score grades 11 body areas from 0 (no hair) to 4 (frankly virile), including the upper lip, chin, chest, upper and lower abdomen, thighs, upper and lower back, arm, forearm, and buttocks. A total score of 8 or more is considered abnormal for an adult white woman; a score of 44 is the most severe.

Obesity

Approximately 50% of women with polycystic ovarian syndrome (PCOS) have abdominal obesity, characterized by a waist circumference greater than 35 inches (>88 cm).

Acanthosis nigricans

Acanthosis nigricans is a diffuse, velvety thickening and hyperpigmentation of the skin. It may be present at the nape of the neck, axillae, area beneath the breasts, intertriginous areas, and exposed areas (eg, elbows, knuckles). In patients with PCOS, acanthosis nigricans is thought to be the result of insulin resistance, although syndromic and familial variants are described. Acanthosis nigricans can also be a cutaneous marker of malignancy.

Acanthosis nigricans is staged according to the scoring system below:

Absent (0): Not detectable on close inspection

Present (1): Clearly present on close visual inspection, not visible to the casual observer, extent not measurable

Mild (2): Limited to the base of the skull, usually does not extend to the lateral margins of the neck

Moderate (3): Extends to the lateral margins of the neck but not visible anteriorly

Severe (4): Visible anteriorly

Severe (5): Circumferential

Blood pressure

Patients with signs and symptoms of metabolic syndrome may have elevated blood pressure, with a systolic blood pressure of 130 mm Hg or higher and a diastolic blood pressure of 85 mm Hg or higher.

Enlarged ovaries

Enlarged ovaries may not always be present. Evaluate for an ovarian mass.

Approach Considerations

The diagnosis of polycystic ovarian syndrome (PCOS) requires the exclusion of all other disorders that can result in menstrual irregularity and hyperandrogenism, including adrenal or ovarian tumors, thyroid dysfunction, congenital adrenal hyperplasia, hyperprolactinemia, acromegaly, and Cushing syndrome. [8, 22, 23] Biochemical and/or imaging studies must be done to rule out these other possible disorders and ascertain the diagnosis. A karyotype usually excludes mosaic Turner syndrome as a cause of the primary amenorrhea.

Patients who are having difficulty conceiving should receive an adequate workup, along with their partners, to rule out factors that might contribute to infertility.

Samples for laboratory studies should be drawn early in the morning, with the patient in a fasting state; in women with regular menses, samples should be taken between days 5 and 9 of the menstrual cycle. [35] A serum human chorionic gonadotropin (hCG) level should be checked to rule out pregnancy in women with oligomenorrhea or amenorrhea.

Screening Laboratory Studies

Women with PCOS should be screened for Cushing syndrome or acromegaly only if there is a clinical suspicion of these conditions. Cushing syndrome can be ruled out by checking a 24-hour urine sample for free cortisol and creatinine. levels of urinary free cortisol that are 4 times the upper limit of normal are diagnostic for Cushing syndrome. [42] An overnight dexamethasone suppression test is also useful for screening for Cushing syndrome.

A small percentage of patients with PCOS have elevated prolactin levels (typically >25 mg/dL). Hyperprolactinemia can be excluded by checking a fasting serum prolactin concentration.

Hormone Levels Androgens

Androstenedione levels are also elevated in women with PCOS. This androgen precursor is 60% ovarian and 40% adrenal in derivation.

Patients with androgen-secreting ovarian or adrenal tumors can present with hirsutism, amenorrhea, and signs of virilization. Although the clinical picture of symptom onset and progression is more predictive than androgen levels, their testosterone level may be greater than 150 ng/dL and their DHEA-S level may be above 800 mcg/dL. DHEA-S is derived from the adrenal gland, and therefore, elevation of DHEA-S would be suggestive of an adrenal origin.

Follicle-stimulating hormone and luteinizing hormone levels

The follicle-stimulating hormone (FSH) level should be checked to rule out primary ovarian failure. In patients with PCOS, FSH levels are within the reference range or low. Luteinizing hormone (LH) levels are elevated for Tanner stage, sex, and age. The LH-to-FSH ratio is usually greater than 3.

Stimulation testing with a long-acting gonadotropin-releasing hormone (GnRH) agonist induces a characteristic rise in ovarian-derived 17-hydroxyprogesterone after 24 hours. This is thought to be a result of excessive 17-hydroxylase activity.

Thyroid-stimulating hormone and free thyroxine levels

Thyroid dysfunction, rather than PCOS, may be the source of amenorrhea and hirsutism. (In patients with PCOS, thyroid function tests are within the reference range.)

Glucose, Insulin, and Lipids

Some women with PCOS have insulin resistance and an abnormal lipid profile (cholesterol >200 mg/dL; LDL >160 mg/dL). Approximately one third of women with PCOS who are overweight have impaired glucose tolerance or type 2 diabetes mellitus by 30 years of age. [44]

A study concluded that insulin resistance and inflammatory markers may help identify adolescent girls with PCOS who are at the highest risk of developing the metabolic syndrome. [45] Metabolic heterogeneity also exists in women with PCOS according to phenotypic subgroup, with metabolic dysfunction confined to the subgroup with both oligomenorrhea and hyperandrogenic features. [46]

Imaging for PCOS Ultrasonography

Ovarian ultrasonography, preferably accomplished by using a transvaginal approach, can be performed to assess ovarian morphology. Perform ultrasonography if the pelvic examination is inadequate, the patient has abdominal pain, testosterone levels are unusually high (eg, >200 ng/dL), it is needed to support the diagnostic criteria, or the patient is amenorrheic (to assess the endometrial thickness and exclude anatomic causes of amenorrhea). (See the image below.)

Longitudinal transabdominal ultrasonogram of an ovary. This image reveals multiple peripheral follicles. CT scan and MRI

If a tumor is suspected, obtain a computed tomography (CT) scan or magnetic resonance image (MRI) to visualize the adrenals and ovaries. MRI is an excellent method for imaging the ovaries and is a useful alternative in very obese women in whom the ovaries might not be visualized with transvaginal ultrasonography (TVUS) and in those patients in whom TVUS is inappropriate, such as adolescent girls.

Histologic Findings

In polycystic ovarian syndrome (PCOS), histologic changes of the ovary include enlarged, sclerotic, multiple cystic follicles (see the image below). As previously stated, a woman is diagnosed with polycystic ovaries (as opposed to PCOS) if she has 12 or more follicles in at least 1 ovary, measuring 2-9 mm in diameter, or a total ovarian volume greater than 10 cm 3 .

Low power, H and E of an ovary containing multiple cystic follicles in a patient with PCOS. Approach Considerations

Certain lifestyle changes, such as diet and exercise, are considered first-line treatment for women with polycystic ovarian syndrome (PCOS). Pharmacologic treatments are reserved for so-called metabolic derangements, such as anovulation, hirsutism, and menstrual irregularities. Medications for such conditions include oral contraceptives, metformin, prednisone, leuprolide, clomiphene, and spironolactone.

Consultation with an endocrinologist is necessary for performing an adrenocorticotropic hormone (ACTH) stimulation test or for other causes of menstrual irregularity such as thyroid disease or pituitary adenoma. A reproductive endocrinologist should be consulted if the patient is infertile and desires pregnancy. [47]

Lifestyle Modifications

The American College of Obstetricians and Gynecologists (ACOG) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) indicate that lifestyle modifications such as weight loss and increased exercise in conjunction with a change in diet consistently reduce the risk of diabetes. This approach has been found to be comparable to or better than treatment with medication and should therefore be considered first-line treatment in managing women with polycystic ovarian syndrome (PCOS). [8, 22] These modifications have been effective in restoring ovulatory cycles and achieving pregnancy in obese women with PCOS. Weight loss in obese women with PCOS also improves hyperandrogenic features.

Drug Treatment

Medical management of PCOS is aimed at the treatment of metabolic derangements, anovulation, hirsutism, and menstrual irregularity. The use of insulin-sensitizing drugs to improve insulin sensitivity is associated with a reduction in circulating androgen levels, as well as improvement in both the ovulation rate and glucose tolerance. [22] The Endocrine Society has published a clinical practice guideline on hirsutism evaluation and treatment in premenopausal women. [48] ACOG notes that eflornithine in conjunction with laser treatment is superior to laser therapy alone in treating hirsutism. [22]

First-line medical therapy usually consists of an oral contraceptive to induce regular menses. The contraceptive not only inhibits ovarian androgen production but also increases sex hormone-binding globulin (SHBG) production. ACOG recommends use of combination low-dose hormonal contraceptive agents for long-term management of menstrual dysfunction. [22] If symptoms such as hirsutism are not sufficiently alleviated, an androgen-blocking agent may be added. Pregnancy should be excluded before therapy with oral contraceptives or androgen-blocking agents is started.

Another study, a double-blind trial by Legro et al, found that letrozole is more effective than clomiphene in the treatment of infertility in PCOS. Based on treatment periods of up to five cycles, the study, which involved 750 anovulatory women with PCOS, found that the birth rates for letrozole and clomiphene were 27.5% and 19.1%, respectively. The rate of congenital abnormalities and the risk of pregnancy loss in the letrozole and clomiphene groups were found to be comparable, although the likelihood of twin births was lower with letrozole. [50, 51]

If the patient develops type 2 diabetes mellitus, consider treatment with oral antihyperglycemic drugs, such as metformin. Metformin can also be considered in other women with PCOS who are insulin resistant and therefore at risk of developing cardiovascular disease, even women without type 2 diabetes.

Clinical trials have shown that metformin can effectively reduce androgen levels, improve insulin sensitivity, and facilitate weight loss in patients with PCOS as early as adolescence. [52, 53, 54, 55] One study concluded that the use of metformin throughout pregnancy was associated with a 9-fold decrease in gestational diabetes in women with PCOS. [56] In addition to having the potential to reduce gestational diabetes in pregnant women with PCOS, metformin may also reduce the risk of preeclampsia in this population. [57]

A long-term study suggested that metformin continued to improve the metabolic profile of women with PCOS over a 36-month treatment course, particularly improving circulating high-density lipoprotein cholesterol (HDL-C), diastolic blood pressure, and body mass index (BMI). [58] However, data are insufficient as yet to recommend metformin to all women with PCOS.

If the patient has concomitant adrenal hyperandrogenism, treatment with low-dose prednisone or dexamethasone may be considered.

Depot leuprolide acetate (Lupron) is effective in suppressing ovarian hormone production, which effectively induces menopause; therefore, this drug must be accompanied by hormone replacement therapy. This treatment approach has not gained widespread favor.

Several medications, including benzoyl peroxide, topical retinoids (Retin-A), and topical and oral antibiotics, are effective for acne treatment. Systemic isotretinoin is used for severe or refractory cases.

FDA Safety Alerts Statins

On March 1, 2012, the US Food and Drug Administration (FDA) updated health care professionals regarding changes to the prescribing information concerning interactions between protease inhibitors (drugs for management of human immunodeficiency virus [HIV] and hepatitis B infection) and certain statin drugs. The combination of these drugs may raise the blood levels of statins and increase the risk for myopathy. Rhabdomyolysis, the most serious form of myopathy, can cause kidney damage and lead to kidney failure, which is life threatening. [59]

On February 28, 2012, the FDA approved important safety label changes for the class of cholesterol-lowering drugs known as statins, including removal of routine monitoring of liver enzymes. Information about the potential for generally nonserious and reversible cognitive side effects and reports of increased blood glucose and glycosylated hemoglobin (HbA1c) levels was added to the statin labels. In addition, extensive contraindication and dose-limitation updates were added to the lovastatin label in situations when this drug is taken with certain medications that can increase the risk for myopathy. [60]

On June 8, 2011, the FDA notified health care professionals of its recommendations for limiting the use of the highest approved dose (80 mg) of the cholesterol-lowering medication simvastatin (Zocor) because of increased risk of muscle damage. The FDA required changes to the simvastatin label to add new contraindications (should not be used with certain medications) and dose limitations for using simvastatin with certain medications. [61]

Sibutramine

On October 8, 2010, Abbott Laboratories and the FDA notified health care professionals and patients about the voluntary withdrawal of the obesity drug sibutramine (Meridia) from the US market because of clinical trial data indicating an increased risk of heart attack and stroke. [62]

Metabolic Derangements

The Androgen Excess and Polycystic Ovary Syndrome Society recommends lifestyle management as the primary therapy for metabolic complications in overweight and obese women with PCOS. [64] A moderate amount of daily exercise increases levels of IGF-1 binding protein and decreases levels of IGF-1 by 20%. Modest weight loss of 2-5% of total body weight can help restore ovulatory menstrual periods in obese patients with PCOS. A decrease of 500-1000 calories daily, along with 150 minutes of exercise per week, can cause ovulation.

Metformin, an antidiabetic drug, improves insulin resistance and decreases hyperinsulinemia in patients with PCOS. [65] This drug also has a small but beneficial effect on metabolic syndrome, as well as potentially causing a modest reduction in androgen levels (11%). [23] Note that women with a body mass index (BMI) greater than 37 kg/m 2 may not have a good response to metformin. [23] An Italian study of 33 patients with PCOS demonstrated that metformin affected thyroid hormone by lowering thyroid-stimulating hormone (TSH) in hypothyroid patients with PCOS, regardless of whether these individuals received levothyroxine or were untreated. [66]

Ascertain that kidney and liver function are normal and that the patient does not have advanced congestive heart failure before starting metformin therapy. The usual starting dose is 500 mg given orally twice a day. Because common adverse effects are nausea, vomiting, and diarrhea, metformin should be taken with meals. Patients who develop these adverse effects can be instructed to decrease the dosage to once a day for a week and then gradually increase the dosage. Also, inform patients that there is a high likelihood that they will have ovulatory cycles while taking metformin. The US Food and Drug Administration (FDA) has not approved metformin for this indication.

Anovulation

The American College of Obstetricians and Gynecologists (ACOG) and Society of Obstetricians and Gynaecologists of Canada (SOGC) recommend clomiphene citrate as first-line therapy to stimulate ovulation when fertility is desired. [8, 22, 24]

Second-line therapy, when clomiphene citrate fails to lead to pregnancy, is either exogenous gonadotropins or laparoscopic ovarian surgery. [8, 22] If gonadotropins are used, a low-dose regimen is recommended, [22] and patients must be monitored with ultrasonography and laboratory studies. [8] Note that gonadotropin therapy is expensive and is associated with an increased risk of multiple pregnancy and ovarian hyperstimulation syndrome. [8]

A study found that N-acetylcysteine may enhance the effect of clomiphene citrate in inducing ovulation in patients with PCOS. [70]

Patients with PCOS who are infertile but desire pregnancy should be referred to a reproductive endocrinologist for further evaluation and management of infertility. Morbidly obese women with PCOS should also be referred for pregnancy risk [8] ; metabolic surgery may be considered in morbidly obese women with PCOS, because many features of this syndrome are reversible with successful weight loss. In vitro fertilization (IVF) is reserved for women with PCOS and unsuccessful gonadotropin therapy or those with other indications for this procedure. [8]

Hirsutism

A clear primary treatment for hirsutism in women with polycystic ovarian syndrome (PCOS) remains lacking. [22] However, short-term, nonpharmacologic treatments of hirsutism include shaving and the use of chemical depilatories and/or bleaching cream. [71] Plucking or waxing unwanted hair can result in folliculitis and ingrown hairs. Long-term, more permanent measures for unwanted hairs include electrolysis and laser treatment.

Adjunctive eflornithine with laser treatment is superior to laser therapy alone in treating hirsutism. [22] Eflornithine (Vaniqa) is a topical cream that can be used to slow hair growth. This agent works by inhibiting ornithine decarboxylase, which is essential for the rapidly dividing cells of hair follicles.

Weight reduction decreases androgen production in women who are obese; therefore, losing weight can slow hair growth.

Women who do not wish to become pregnant can be effectively treated for hirsutism with oral contraceptives. [72] Oral contraceptives slow hair growth in 60-100% of women with hyperandrogenemia. Therapy can be started with a preparation that has a low dose of estrogen and a nonandrogenic progestin. Preparations that have norgestrel and levonorgestrel should be avoided because of their androgenic activity. There is also a risk of thrombotic events in obese women who use oral contraceptives; therefore, the proper precautions should be exercised to prevent such events. Oral contraceptives containing cyproterone acetate are also very effective in the treatment of more severe hirsutism [73] ; however, this combination of agents has not been approved by the FDA for use in the United States.

Antiandrogens, such as spironolactone, are effective for hirsutism. [74] Spironolactone (50-100 mg twice daily) is an effective primary therapy for hirsutism. Because of the potential teratogenic effects of spironolactone, patients require an effective form of contraception (eg, an oral contraceptive). Adverse effects of spironolactone include gastrointestinal discomfort and irregular menstrual bleeding, which can be managed by adding an oral contraceptive.

Ovulation induction with clomiphene citrate, metformin, or both does not alter hirsutism in infertile hirsute women with PCOS. [75]

Diet and Activity

Patients with polycystic ovarian syndrome (PCOS) who have impaired glucose tolerance should start a comprehensive program of diet and exercise to reduce their risk of developing diabetes mellitus. Encourage moderate physical activity, provided the patient has no contraindications. Discourage smoking because of the increased risk of cardiovascular disease. In addition, obese women with PCOS can benefit from a low-calorie diet for weight reduction.

A diet patterned after the type 2 diabetes diet has been recommended for PCOS patients. [76] This diet emphasizes increased fiber; decreased refined carbohydrates, trans fats, and saturated fats; and increased omega-3 and omega-9 fatty acids. However, in some obese patients with PCOS, weight loss has improved menstrual regularity. [77] Omega-3 fatty acid supplementation has been shown to reduce liver fat content and other cardiovascular risk factors in women with PCOS, including those with hepatic steatosis, although these effects have not yet been proven to translate into a reduction in cardiometabolic events. [78]

Women with an abnormal lipid profile should be counseled on ways to manage the dyslipidemia. Such measures include eating a diet low in cholesterol and saturated fats and increasing physical activity. Guidelines from the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, or ATP III) (2001) serve as a guide for the treatment of women with PCOS and dyslipidemia. The NCEP is currently updating the ATP III guidelines; Readers are encouraged to check the National Health Lung and Blood Institute Web site for the most recent guidelines: http:/ / www.nhlbi.nih.gov/ guidelines/ cholesterol/ atp4/ index.htm

Accumulating evidence suggests an association of vitamin D deficiency with metabolic syndrome. One study found insufficient levels of 25-hydroxyvitamin D ( [79]

Surgical Intervention

Surgical management of polycystic ovarian syndrome (PCOS) is aimed mainly at restoring ovulation. Ovarian wedge resection has fallen out of favor because of postoperative adhesion formation and the successful introduction of ovulation-inducing medications.

Various laparoscopic methods, including electrocautery, laser drilling, and multiple biopsy, have been used with the goal of creating focal areas of damage in the ovarian cortex and stroma. According to the Society of Obstetricians and Gynaecologists of Canada (SOGC), laparoscopic ovarian drilling may be considered in women with clomiphene-resistant PCOS, especially in the presence of other laparoscopic indications. [8] A small French study also suggested that surgical management via ovarian drilling with hydrolaparoscopy may be beneficial in cases of PCOS that are resistant to clomiphene citrate. [80]

Potential complications must be considered as well. These include formation of adhesions and ovarian atrophy. Multiple pregnancy rates are lower with ovarian drilling than with gonadotropin treatment (1% vs 16%, respectively), but there are ongoing concerns about the long-term effects of ovarian drilling on ovarian function. [81]

Long-Term Monitoring

Polycystic ovarian syndrome (PCOS) is a disease with many long-term complications. Patients need regular follow-up with their physicians for early detection and management of any untoward sequelae associated with the syndrome (see Prognosis).

Women with PCOS who conceive are at increased risk for gestational diabetes, preeclampsia, cesarean delivery, and preterm and postterm delivery. In addition, their newborns are at increased risk of being large for gestational age, but they are not at increased risk of stillbirth or neonatal death. [82]

Participation in a peer support group may alleviate distress and improve self-management. [83]

Medication Summary

An oral contraceptive containing ethinyl estradiol and a progestin with minimal androgenic activity, such as norgestimate, norethindrone, or desogestrel, should be selected. Ethinyl estradiol combined with drospirenone (Yasmin) has a progestin that acts as an antiandrogen and thus may add antiandrogenic effects.

Withdrawal bleeding can be induced with medroxyprogesterone (Provera) given for 5-10 days before the start of oral contraceptive therapy. Pregnancy must be ruled out before oral contraceptive therapy is started.

The indications, contraindications, and adverse effects of metformin therapy should be carefully reviewed with the patient before such therapy is begun. In addition, women starting metformin therapy should be informed that such treatment may result in ovulatory menstrual cycles and increase the probability of pregnancy. It is worth noting that metformin has the potential to reduce preeclampsia and gestational diabetes in pregnant women with PCOS. [57]

Women taking spironolactone require reliable contraception. An oral contraceptive is preferable, but if that form of contraception is contraindicated, another type of contraception should be used.

FDA safety alerts

On March 1, 2012, the US Food and Drug Administration (FDA) notified health care professionals of updates to the prescribing information concerning interactions between protease inhibitors (drugs for management of human immunodeficiency virus [HIV] and hepatitis B infection) and certain statin drugs. Protease inhibitors and statins taken together may raise the blood levels of statins and increase the risk for muscle injury (myopathy). The most serious form of myopathy, called rhabdomyolysis, can damage the kidneys and lead to kidney failure, which can be fatal.

On February 28, 2012, the FDA approved important safety label changes for the class of cholesterol-lowering drugs known as statins. The changes include removal of routine monitoring of liver enzymes from drug labels. Information about the potential for generally non-serious and reversible cognitive side effects and reports of increased blood glucose and glycosylated hemoglobin (HbA1c) levels has been added to the statin labels. The lovastatin label has been extensively updated with new contraindications and dose limitations when it is taken with certain medicines that can increase the risk for muscle injury.

On June 8, 2011, the FDA notified health care professionals that it recommended limiting the use of the highest approved dose of the cholesterol-lowering medication simvastatin (80 mg) because of increased risk of muscle damage. The FDA required changes to the simvastatin label to add new contraindications (should not be used with certain medications) and dose limitations for using simvastatin with certain medicines.

On October 8, 2010, Abbott Laboratories and the FDA notified health care professionals and patients about the voluntary withdrawal of sibutramine (Meridia), an obesity drug, from the US market because of clinical trial data indicating an increased risk of heart attack and stroke.

Metformin (Glucophage, Glumetza, Riomet, Fortamet) Insulin (Humulin, Novolin) Class Summary

These agents reduce blood glucose levels.

Spironolactone (Aldactone) Leuprolide (Lupron, Eligard) Finasteride (Proscar, Propecia) Class Summary

Antiandrogen agents block androgen receptors, thereby inhibiting the effects of male sex hormones. These agents may be used to treat hirsutism in women with PCOS.

Eflornithine (Veniqa)

Note: The use of eflornithine has been studied only on the face and adjacent involved areas under the chin of individuals with hypertrichosis; therefore, limit use of this drug to these areas. Patients will likely need other hair-removal methods in conjunction with eflornithine therapy.

Class Summary

Eflornithine cream can be used to treat androgen excess.

Ethinyl estradiol Medroxyprogesterone (Depo-Provera, Provera) Class Summary

Oral contraceptive agents reduce the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary gland by decreasing the amount of gonadotropin-releasing hormone (GnRH). All oral contraceptives decrease ovarian androgen production. By inhibiting gonadotropin secretion and, therefore, tertiary follicle development, ovarian secretion of testosterone and androstenedione is decreased. All oral contraceptives increase sex hormone-binding globulin (SHBG) and, therefore, reduce free testosterone. Evidence indicates that high doses of contraceptive progestins may inhibit 5-alpha reductase. Oral contraceptives also decrease the production of adrenal androgens, particularly dehydroepiandrosterone sulfate (DHEA-S).

Different contraceptive preparations have different effects on ovarian androgen production and SHBG. However, they all reduce levels of free testosterone equally (by approximately 50%). Free testosterone levels achieved with oral contraceptive preparations are unrelated to the increased levels of SHBG. Preparations that result in higher SHBG levels also result in higher total testosterone levels. That is, a decrease in free testosterone level is the same for all oral contraceptives and, although some of these preparations increase SHBG levels more than others, this is off-set by a concomitant increase in total testosterone level.

Restoration of regular menstrual cycles prevents endometrial hyperplasia associated with anovulation. Oral contraceptives also improve acne and hirsutism.

Clomiphene citrate (Clomid, Serophene) Class Summary

Clomiphene citrate, a selective estrogen receptor modulator, binds to estrogen receptors, inducing ovulation by increasing the output of pituitary gonadotropins.

Benzoyl peroxide (Benzac AC Gel, Desquam-X, Benzac AC Wash, BenzEFoam, BPO Creamy Wash Complete Pack, BPO Foaming Cloth, BPO Gel, Clean and Clear Advantage 3-in-1 Exfoliating Cleanser, Clean and Clear Continuous Control Acne Cleanser, Clean and Clear Gel, Clearasil Vanishing Acne Treatment Cream, Lavoclen-4 Creamy Wash, Lavoclen-8 Creamy Wash, NeoBenz Micro, NeoBenz Micro SD, NeoBenz Micro Wash, Neutrogena Benzoyl Peroxide Lotion, Neutrogena Clear Pore Acne Treatment, Neutrogena On-The-Spot Acne Treatment, Neutrogena Clear Pore Daily Scrub, PanOxyl Acne Cleansing Bar, PanOxyl Acne Creamy Wash, PanOxyl Acne Foaming Wash, Proactiv, Proactiv Advanced Blemish Treatment, Proactiv Renewing Cleanser, Proactiv Repairing, Zapzyt Acne Treatment Gel) Adapalene topical cream 0.1%; gel 0.1 and 0.3%; lotion 0.1% (Differin) Erythromycin topical 2% (AkneMycin, Ery) Clindamycin topical 1% (Cleocin T, ClindaReach, ClindaDerm, Clindagel, ClindaMax, Clindets, Evoclin) Sodium Sulfacetamide topical 10% (Klaron) Class Summary

Various topical over-the-counter (OTC) and prescription agents are available to treat acne occurring with polycystic ovarian syndrome (PCOS).

Author

Richard Scott Lucidi, MD, FACOG, Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editors

Frances E Casey, MD, MPH, Director of Family Planning Services, Department of Obstetrics and Gynecology, VCU Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Richard Scott Lucidi, MD, FACOG, Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Elizabeth Alderman, MD Director of Fellowship Training Program, Director of Adolescent Ambulatory Service, Professor of Clinical Pediatrics, Department of Pediatrics, Division of Adolescent Medicine, Albert Einstein College of Medicine and Children's Hospital at Montefiore

Elizabeth Alderman, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, North American Society for Pediatric and Adolescent Gynecology, and Society for Adolescent Medicine

Disclosure: Merck Honoraria Speaking and teaching

A David Barnes, MD, PhD, MPH, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association

Disclosure: Nothing to disclose.

Robert J Ferry Jr, MD Le Bonheur Chair of Excellence in Endocrinology, Professor and Chief, Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, University of Tennessee Health Science Center

Robert J Ferry Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Diabetes Association, American Medical Association, Endocrine Society, Pediatric Endocrine Society, Society for Pediatric Research, and Texas Pediatric Society

Disclosure: Eli Lilly & Co Grant/research funds Investigator; MacroGenics, Inc Grant/research funds Investigator; Ipsen, SA (formerly Tercica, Inc) Grant/research funds Investigator; NovoNordisk SA Grant/research funds Investigator; Diamyd Grant/research funds Investigator; Bristol-Myers-Squibb Grant/research funds Other; Amylin Other; Pfizer Grant/research funds Other; Takeda Grant/research funds Other

Stephen Kemp, MD, PhD Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas for Medical Sciences College of Medicine, Arkansas Children's Hospital

Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Lynne Lipton Levitsky, MD Chief, Pediatric Endocrine Unit, Massachusetts General Hospital; Associate Professor of Pediatrics, Harvard Medical School

Lynne Lipton Levitsky, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Diabetes Association, American Pediatric Society, Endocrine Society, Pediatric Endocrine Society, and Society for Pediatric Research

Disclosure: Pfizer Grant/research funds P.I.; Tercica Grant/research funds Other; Eli Lily Grant/research funds PI; NovoNordisk Grant/research funds PI; NovoNordisk Consulting fee Consulting; Onyx Heart Valve Consulting fee Consulting

Jordan G Pritzker, MD, MBA, FACOG Assistant Professor of Obstetrics/Gynecology and Women's Health, Women's Comprehensive Health Center, Hofstra University School of Medicine; Attending Physician, Department of Obstetrics and Gynecology, Long Island Jewish Medical Center

Disclosure: Nothing to disclose.

Kathy Silverman, DO Albert Einstein College of Medicine and Montefiore Medical Center

Disclosure: Nothing to disclose.

Phyllis W Speiser, MD Chief, Division of Pediatric Endocrinology, Steven and Alexandra Cohen Children's Medical Center of New York; Professor of Pediatrics, Hofstra-North Shore LIJ School of Medicine at Hofstra University

Phyllis W Speiser, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, Endocrine Society, Pediatric Endocrine Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Andrea Leigh Zaenglein, MD Associate Professor of Dermatology and Pediatrics, Department of Dermatology, Milton S Hershey Medical Center, Pennsylvania State University College of Medicine

Andrea Leigh Zaenglein, MD is a member of the following medical societies: American Academy of Dermatology, American Acne and Rosacea Society, and Society for Pediatric Dermatology

Disclosure: Nothing to disclose.

References Longitudinal transabdominal ultrasonogram of an ovary. This image reveals multiple peripheral follicles. Longitudinal transabdominal ultrasonogram of an ovary. This image reveals multiple peripheral follicles.

Cleocin (Clindareach) Delivery

You can order delivery of a Cleocin (Clindareach) to the Germany, France, Australia or any other country in the world. Residents of the USA can order Cleocin (Clindareach) to any city, to any address, for example to Columbus, Ft Lauderdale, Denver or Chicago.